ACCEPTED: CLINICAL VIGNETTES/CASE REPORTS—ESOPHAGUS
A Case Tough to Swallow: Esophageal Intramural Pseudodiverticulosis
Esophageal intramural pseudodiverticulosis (EIP) is a rare condition characterized by multiple small outpouchings protruding from the esophageal lumen to the outer wall. The pseudodiverticula represent dilated excretory ducts of deep esophageal mucosal glands. The most common symptom is dysphagia with esophageal stricture formation. In this case, we present a 62 year-old lady who suffered from dysphagia and unintentional weight loss, and was diagnosed to have EIP by esophagogram and esophagogastroduodenoscopy (EGD) which improved after dilatational therapy. A 62 year old female with a history of liver cirrhosis, chronic pancreatitis, and gastroesophageal reflux disease presented with nausea, vomiting, and melena. Social history was significant for smoking (25 pack/yr.), and chronic alcoholism. Initial exam revealed a thin, malnourished woman in overall poor health who endorsed dysphagia with regurgitation of solid food, and ongoing unintentional weight loss. Her labs exhibited an AST (71u/L), ALT (122 u/L), and Hgb (5.6 g/dL). EGD and colonoscopy were planned to workup her anemia, and dysphagia. EGD, displayed severe stenosis in the proximal esophagus that was dilated with 8 mm TTS (Through the Scope) dilator. Subsequently, she was sent for esophagram which displayed numerous submucosal collections of contrast in the upper portion of the esophagus, consistent with EIP. Repeat EGD showed benign esophageal stenosis with pseudodiverticula in the upper third of the esophagus. The stenosis was dilated with 24 and 27 Fr dilators leading to resolution of her dysphagia, and on follow up she is tolerating a full diet. EIP is a rare condition with approximately 200 cases reported world-wide. Two mechanisms of proposed injury predominate; excretory ductal obstruction secondary to inflammation, and submucosal fibrosis caused by chronic irritation. Reports have shown the risks of developing EIP are higher in those who have coexisting disease such as esophageal candidiasis, diabetes mellitus, or corrosive injury. One study found a statistically significant difference between prevalence of EIP in patients with esophageal cancer (4.5%) and of those without cancer (0.09%). Given more than 80% of patients with EIP experience stenosis and dysphagia, endoscopic dilation has proven to alleviate symptoms longterm. Our case expands the potential causes of dysphagia, and emphasizes the importance of ruling out potentially serious underlying causes associated with EIP.© The American College of Gastroenterology 2018. All Rights Reserved.